THE MOST UP TO DATE POSTURE RESEARCH

It’s been a while since I have done a review of research relevant to good and bad posture. And in that time some things have changed – the most noticeable is that if you look closely in the following papers you should notice that digital photography and the objective measurements possible as a result are a key feature. Now I don’t hate to tell you that “I told you so” – but I have been pushing the use of digital postural analysis since about 1996!

The other clear point from the following abbreviated abstracts is just how powerful postural analysis is as an outcome tool, and a predictor of morbidity. If you are not incorporating objective postural analysis and including corrective strategies that work in your practice – then WHY NOT?

Historically, clinicians visually evaluate posture using anatomical landmarks. Advances in technology made digital photographs now feasible to use in clinical practice. Photogrammetry may increase the reliability of the assessment of postural changes. However, differences between visually estimated and photogrammetric recorded changes in posture need to be tested. The objective of this study was to evaluate the sensitivity of visual assessments of changes in head posture in the sagittal plane in relation to photogrammetric recorded data… Visual assessments of sagittal head posture were sensitive to detect differences between no FHP and FHP groups, but were not sensitive to detect differences between no FHP and slight FHP groups.Head posture photogrammetry is recommended to quantitatively detect less evident differences in head posture.

2) Differences in Standing and Sitting Postures of Youth with Idiopathic Scoliosis from Quantitative Analysis of Digital Photographs.

The objective of this study was to explore whether differences in standing and sitting postures of youth with idiopathic scoliosis could be detected from quantitative analysis of digital photographs. Standing and sitting postures of 50 participants aged 10-20-years-old with idiopathic scoliosis (Cobb angle: 15° to 60°) were assessed from digital photographs using a posture evaluation software program… Significant differences between standing and sitting positions (p < 0.05) were found for head protraction, shoulder elevation, scapula asymmetry, trunk list, scoliosis angle, waist angles, and frontal and sagittal plane pelvic tilt. Quantitative analysis of digital photographs is a clinically feasible method to measure standing and sitting postures among youth with scoliosis and to assist in decisions on therapeutic interventions.

3) Trunk deformity is associated with a reduction in outdoor activities of daily living and life satisfaction in community-dwelling older people.

We have evaluated the association between trunk deformities of the sagittal plane and functional impairment of daily living in community-dwelling elderly subjects. The analysis involved a detailed assessment of indoor and outdoor activities of daily living, satisfaction with life, and mental status. The participants in this study were 236 community-dwelling older adults, aged 65 years and older, living in Kahoku district of Kochi in Japan. The participants were classified based on their posture, which was assessed using photographs of the subjects, and interviewed to assess their basic activities of daily living (BADL), instrumental ADL (IADL), and cognitive well-being in the cross-sectional study… The lumbar kyphosis group received significantly lower BADL and IADL scores than the normal group. The trunk deformity group which were defined as kyphosis, flat back, and lumbar lordosis groups exhibited decreases in activities that included going out, shopping, depositing and withdrawing money, and visiting friends in the hospital. These activities require going outdoors; thus, this study showed that the trunk deformity group had limitations in outdoor activities… The abnormal trunk deformity groups tended to score lower than the normal group with regard to subjective healthiness and life satisfaction measures, including subjective health condition, everyday feeling, satisfaction with human relationships, satisfaction with economic condition, and satisfaction with present life.

4) Video analysis of sagittal spinal posture in healthy and young adults

Changes in posture are of concern because of their association with pain or impaired physical function… Compared to young adults, healthy older adults demonstrated a forward head posture, with increased lower cervical spine flexion and increased upper cervical extension in both positions. Older adults also sat with significantly increased thoracic kyphosis and decreased lumbar spine flexion… The angular relationship between adjacent spinal regions in the sagittal plane can be objectively quantified using image-based analysis. The concept that the anteroposterior tilt of the pelvis in standing dictates the lumbar and thoracic curves was supported by the correlations between these adjacent regions in both age groups. The model of skin marker placement used in this study can have a broader application as a clinical tool for image-based postural assessment.

Seventy participants aged between 10 and 20 years with different types of idiopathic scoliosis (Cobb angle 15 to 60°) were recruited from the scoliosis clinic… Based on the XY co-ordinates of natural reference points (e.g., eyes) as well as markers placed on several anatomical landmarks, 32 angular and linear posture indices taken from digital photographs in the standing position were calculated from a specially developed software program…Posture can be assessed in a global fashion from photographs in persons with idiopathic scoliosis. Despite the good reliability of marker placement, other studies are needed to minimise measurement errors in order to provide a suitable tool for monitoring change in posture over time.

6) Postural compensations and subjective complaints due to backpack loads and wear time in schoolchildren.

This study investigated the effects of carrying weighted backpacks of up to 20% of body weight on the posture and pain complaints of elementary-school children. Craniovertebral, forward trunk lean and pelvic tilt angles were measured from sagittal photographs of 62 children (8-11 years old) before and after walking while carrying backpacks containing 10%, 15%, or 20% of body weight. Pain severity after a 6-minute walk with the loaded backpack was recorded. Subjective complaints of pain were assessed using a visual analog scale after walking. Repeated-measures ANOVA revealed statistically significant differences in postural angles and increased complaints of pain after walking with increased backpack loads. These results indicate that typical backpack loads create worsening postural changes due to backpack loads and time spent carrying those loads, putting children at increased risk for injury and pain, the latter of which is a strong predictor for back pain in adulthood.

This study examined the effects of various backpack loads on elementary schoolchildren’s posture and postural compensations as demonstrated by a change in forward head position. Sagittal digital photographs were taken of each subject standing without a backpack, and then with the loaded backpack before and after walking 6 minutes (6MWT) at free walking speed. This was repeated over three consecutive weeks using backpacks containing randomly assigned weights of 10%, 15%, or 20% body weight of each respective subject. The craniovertebral angle (CVA) was measured using digitizing software, recorded and analyzed. Subjects demonstrated immediate and statistically significant changes in CVA, indicating increased forward head positions upon donning the backpacks containing 15% and 20% body weight. Following the 6MWT, the CVA demonstrated further statistically significant changes for all backpack loads indicating increased forward head postures. For the 15 & 20%BW conditions, more than 50% of the subjects reported discomfort after walking, with the neck as the primary location of reported pain.

Effect of backpack weight on postural angles in preadolescent children.

Carrying heavy backpacks could cause a wide spectrum of pain related musculoskeletal disorders and postural dysfunctions. To determine the changes in various postural angles with different backpack weights in preadolescent children… digitizing software was used for analyzing photographs to determine craniovertebral (CV), head on neck (HON), head and neck on trunk (HNOT), trunk and lower limb angles. Postural angles were compared with no backpack and with backpacks weighing 5% to 25% of the subject’s bodyweight. The CV angle changed significantly after 15% of backpack load (P <0.05). The HON and HNOT angles changed significantly after 10% of backpack load (P <0.05). The trunk and lower limb angle also changed significantly after 5% of backpack load (P <0.05). Carrying a backpack weighing 15% of body weight change all the postural angles in preadolescent children.

9) Spinal Posture in the Sagittal Plane Is Associated With Future Dependence in Activities of Daily Living: A Community-Based Cohort Study of Older Adults in Japan.

Accumulated evidence shows how important spinal posture is for aged populations in maintaining independence in everyday life. However, the cross-sectional designs of most previous studies prevent elucidation of the relationship between spinal posture and future dependence in activities of daily living (ADL). We tried to clarify the association by measuring spinal posture noninvasively in a community-based prospective cohort study of older adults, paying particular attention to thoracic curvature, lumbar curvature, sacral hip angle, and inclination to determine which parameter is most strongly associated with dependence in ADL… This study indicates that spinal inclination is associated with future dependence in ADL among older adults.

10) Association of spinal inclination with physical performance measures among community-dwelling Japanese women aged 40 years and older.

Spinal inclination assesses spinal posture as a whole. However, the association between spinal inclination and physical performance has not yet been fully elucidated. Therefore, this study aimed to explore the association of spinal inclination with physical performance measures. The participants were 107 Japanese women aged 40-84 years. Spinal posture was assessed as inclination to a perpendicular line by using a computer-assisted device. Increased inclination value means forward inclination of the spine. Physical performance was measured by using the following methods: 6-m walking time, chair stand time, functional reach, Timed Up & Go Test, and grip strength. Information on participants’ comorbidities, osteoporosis, knee joint pain, back pain, falls in the previous year, regular exercise and usage of non-steroidal anti-inflammatory drugs (NSAIDs), was also collected. Pearson’s correlation analysis showed significant associations between spinal inclination and all of the physical performance measures. Pearson’s partial correlation analysis adjusted for age showed significant associations of increased inclination with poor physical functioning in 6-m walking time, chair stand time, functional reach, and Timed Up & Go Test, but not in grip strength. Linear regression analysis adjusted for age, grip strength, number of comorbidities, osteoporosis, knee joint pain, back pain, falls in previous year, regular activity and taking NSAIDs showed that spinal inclination was associated with poor function in 6-m walking time, chair stand time, functional reach and Timed Up & Go Test. Forward spinal inclination was associated with impairment in various physical performance measures. Proper prevention and treatment of underlying disorders should be prompted.

The aim of this study is to perform a screening of patients diagnosed with ankylosing spondylitis (AS) in order to evaluate the static spinal disorders and correlate the results with the main clinical and functional parameters that characterize this disease… The assessment of lumbosacral pain in the morning and daytime lumbosacral pain showed a higher scores in patients suffering from kyphoscoliosis than in those with scoliosis, or kyphosis. Ott and modified Schöber index, and chest expansion, had higher mean values in patients with scoliosis compared with the other postural disorders. Statistically higher mean BASFI values were recorded in patients with kyphoscoliosis, while the mean BASMI values were lower in scoliosis patients. As to the quality of life of AS patients, HAQ-DI index recorded significantly lower mean values for kyphoscoliosis compared with other postural disorders. Our study suggests that posture assessment and implicitly the correction of possible misalignments should be part of the kinetic physical therapy program. Rigorous observing of postural recommendations can prevent the respiratory system complications.

12) Effects of thoracic kyphosis and forward head posture on cervical range of motion in older adults.

Man Ther. 2013 Feb;18(1):65-71. Quek J, Pua YH, Clark RA, Bryant AL.

It is unclear how age-related postural changes such as thoracic spine kyphosis influence cervical range-of-motion (ROM) in patients with cervical spine dysfunction. The purpose of this study was to explore the mediating effects of forward head posture (FHP) on the relationship between thoracic kyphosis and cervical mobility in older adults with cervical spine dysfunction. Fifty-one older adults… with cervical spine dysfunction – that is, cervical pain with or without referred pain, numbness or paraesthesia – participated. Pain-related disability was measured using the neck disability index (NDI). Thoracic kyphosis was measured using a flexicurve. FHP was assessed via the craniovertebral angle (CVA) measured from a digitized, lateral-view photograph of each subject. Cervical ROM - namely, upper and general cervical rotation and cervical flexion – was measured by the Cervical Range-of-Motion (CROM) device. Greater thoracic kyphosis was significantly associated with lesser CVA whereas greater CVA was significantly associated with greater cervical flexion and general rotation ROM, but not with upper cervical rotation ROM… Our results show that FHP mediated the relationship between thoracic kyphosis and cervical ROM, specifically general cervical rotation and flexion. These results not only support the justifiable attention given to addressing FHP to improve cervical impairments, but they also suggest that addressing thoracic kyphosis impairments may constitute an “upstream” approach.

To compare the amount of forward head posture (FHP) and cervical range of motion between patients with moderate carpal tunnel syndrome (CTS) and healthy controls. We also sought to assess the relationships among FHP, cervical range of motion, and clinical variables related to the intensity and temporal profile of pain due to CTS… FHP and cervical range of motion were assessed in 25 women with CTS and 25 matched healthy women. Side-view pictures were taken in both relaxed-sitting and standing positions to measure the craniovertebral angle. A CROM device was used to assess cervical range of motion. Posture and mobility measurements were performed by an experienced therapist blinded to the subjects’ condition… Patients with mild/moderate CTS exhibited a greater FHP and less cervical range of motion, as compared to healthy controls. Additionally, a greater FHP was associated with a reduction in cervical range of motion…

14) The role of forward head correction in management of adolescent idiopathic scoliotic patients: a randomized controlled trial.

Clin Rehabil. 2012 Dec;26(12):1123-32. Diab AA.

To investigate the effectiveness of forward head correction on three-dimensional posture parameters and functional level in adolescent idiopathic scoliotic patients… All the patients (n = 76) received traditional treatment in the form of stretching and strengthening exercises. In addition, patients in the study group (n = 38) received a forward head posture corrective exercise programme… Craniovertebral angle, Functional Rating Index and posture parameters, including: lumbar lordosis, thoracic kyphosis, trunk inclination, trunk imbalance, lateral deviation, surface rotation and pelvis torsion were measured before treatment, after 10 weeks, and at three-month follow-up… A forward head corrective exercise programme combined with conventional rehabilitation improved three-dimensional scoliotic posture and functional status in patients with adolescent idiopathic scoliosis.

15) The efficacy of forward head correction on nerve root function and pain in cervical spondylotic radiculopathy: a randomized trial.

Clin Rehabil. 2012 Apr;26(4):351-61. Diab AA, Moustafa IM.

To investigate the effect of forward head posture correction on pain and nerve root function in cases of cervical spondylotic radiculopathy… Ninety-six patients with unilateral lower cervical spondylotic radiculopathy (C5-C6 and C6-C7) and craniovertebral angle measured less than or equal to 50° were randomly assigned to an exercise or a control group… The control group (n = 48) received ultrasound and infrared radiation, whereas the exercise group (n = 48) received a posture corrective exercise programme in addition to ultrasound and infrared radiation… Forward head posture correction using a posture corrective exercise programme in addition to ultrasound and infrared radiation decreased pain and craniovertebral angle and increased the peak-to-peak amplitude of dermatomal somatosensory evoked potentials for C6 and C7 in cases of lower cervical spondylotic radiculopathy.

16) The effect of the forward head posture on postural balance in long time computer based worker.

To estimate the effects of a relatively protruded head and neck posture on postural balance, in computer based worker… Thirty participants, who work with computers for over 6 hrs per day (Group I), and thirty participants, who rarely work with computers (Group II), were enrolled. The head and neck posture was measured by estimating angles A and B. A being the angle between the tragus of the ear, the lateral canthus of the eye, and horizontal line and B the angle between the C7 spinous process, the tragus of the ear, and the horizontal line. The severity of head protrusion with neck extension was assessed by the subtraction of angle A from angle B. We also measured the center of gravity (COG) and postural balance by using computerized dynamic posturography to determine the effect of computer-based work on postural balance… The results of this study suggest that forward head postures during computer-based work may contribute to some disturbance in the balance of healthy adults. These results could be applied to education programs regarding correct postures when working at a computer for extended periods of time.

The mechanical alterations related to the overload of respiratory muscles observed in adults with persistent asthma might lead to the development of chronic alterations in posture, musculoskeletal dysfunction and pain; however, these changes remain poorly understood… This study aimed to assess postural alignment, muscle shortening and chronic pain in adults with persistent asthma… In comparison with non-asthmatic subjects, patients with mild or severe persistent asthma held their head and shoulders more forward and had lower chest wall expansion, decreased shoulder internal rotation, and decreased thoracic spine flexibility. Chronic lower thoracic, cervical, and shoulder pain was significantly increased in patients with mild or severe asthma compared with non-asthmatic subjects…

18) Head and shoulder alignment among patients with unilateral vestibular hypofunction.

To investigate head and shoulder alignment among patients with unilateral vestibular hypofunction (UVH), using computerized biophotogrammetry (CB) and to correlate these measurements with gender, age, duration of clinical evolution, self-perception of intensity of dizziness and occurrences of falls… The patients with UVH had greater forward and lateral head deviation angles than did the normal individuals, with a statistically significant difference… Forward head was associated with the duration of clinical symptoms of the vestibular disease, age, intensity of dizziness and occurrence of falls.

We assessed the effects of forward head posture in the sitting position on the activity of the scapular upward rotators during loaded isometric shoulder flexion in the sagittal plane. Healthy volunteers (n = 21; 11 men, 10 women) with no history of pathology participated in the study. Subjects were instructed to perform isometric shoulder flexion with the right upper extremity in both the forward head posture (FHP) and neutral head posture (NHP) while sitting. Surface electromyography (EMG) was recorded from the upper trapezius, lower trapezius, and serratus anterior muscles… Significantly increased EMG activity in the upper trapezius and lower trapezius and significantly decreased EMG activity in the serratus anterior were found during loaded isometric shoulder flexion with FHP. Thus, FHP may contribute to work-related neck and shoulder pain during loaded shoulder flexion while sitting. These results suggest that maintaining NHP is advantageous in reducing sustained upper and lower trapezius activity and enhancing serratus anterior activity as compared with FHP during loaded shoulder flexion.

Forward head and rounded shoulder posture (FHRSP) is theorized to contribute to alterations in scapular kinematics and muscle activity leading to the development of shoulder pain. However, reported differences in scapular kinematics and muscle activity in those with forward head and rounded shoulder posture are confounded by the presence of shoulder pain. Therefore, the purpose of this study was to compare scapular kinematics and muscle activity in individuals free from shoulder pain, with and without FHRSP. Eighty volunteers were classified as having FHRSP or ideal posture. Scapular kinematics were collected concurrently with muscle activity from the upper and lower trapezius as well as the serratus anterior muscles during a loaded flexion and overhead reaching task using an electromagnetic tracking system and surface electromyography. Separate mixed model analyses of variance were used to compare three-dimensional scapular kinematics and muscle activity during the ascending phases of both tasks. Individuals with FHRSP displayed significantly greater scapular internal rotation with less serratus anterior activity, during both tasks as well as greater scapular upward rotation, anterior tilting during the flexion task when compared with the ideal posture group. These results provide support for the clinical hypothesis that FHRSP impacts shoulder mechanics independent of shoulder pain.

The aim of this study was to assess the influence of cranio-cervical posture on the maximal mouth opening (MMO) and pressure pain threshold (PPT) in patients with myofascial temporomandibular pain disorders… The results of this study shows that the experimental induction of different cranio-cervical postures influences the MMO and PPT values of the temporomandibular joint and muscles of mastication that receive motor and sensory innervation by the trigeminal nerve. Our results provide data that supports the biomechanical relationship between the cranio-cervical region and the dynamics of the temporomandibular joint, as well as trigeminal nociceptive processing in different cranio-cervical postures.

The aim of this study was to verify possible relationships between global body posture and temporomandibular joint internal derangement (TMJ-id), by comparing 30 subjects presenting typical TMJ-id signs to 20 healthy subjects. Body posture was assessed using the analysis of muscle chains on several photographs… There was a trend noticed in the group with the most severe dysfunction, to present a forward head and shoulders posture…

To identify the relationship between anterior disc displacement and global posture (plantar arches, lower limbs, shoulder and pelvic girdle, vertebral spine, head and mandibles). Common signs and symptoms of anterior disc displacement were also identified… Global posture deviations cause body adaptation and realignment, which may interfere with the organization and function of the temporomandibular joint… Our results suggest a close relationship between body posture and temporomandibular disorder, though it is not possible to determine whether postural deviations are the cause or the result of the disorder. Hence, postural evaluation could be an important component in the overall approach to providing accurate prevention and treatment in the management of patients with temporomandibular disorder.

The aim of this pilot study was to add weight to a hypothesis according to which patients presenting with chronic neck pain could have a predisposition towards respiratory dysfunction. Twelve patients with chronic neck pain and 12 matched controls participated in this study. Spirometric values, maximal static pressures, forward head posture and functional tests were examined in all subjects. According to the results, chronic neck patients presented with a statistically significant decreased maximal voluntary ventilation and respiratory muscle strength. Furthermore, the current study demonstrated a strong association between an increased forward head posture and decreased respiratory muscle strength in neck patients. The connection of neck pain and respiratory function could be an important consideration in relation to patient assessment, rehabilitation and consumption of pharmacological agents.

There are several reports suggesting that forward head posture is associated with temporomandibular disorders and restraint of mandibular growth, possibly due to mandibular displacement posteriorly. However, there have been few reports in which the condylar position was examined in forward head posture. The purpose of this study was to test the hypothesis that the condyle moves posteriorly in the forward head posture. The condylar position and electromyography from the masseter, temporal and digastric muscles were recorded on 15 healthy male adults at mandibular rest position in the natural head posture and deliberate forward head posture. The condylar position in the deliberate forward head posture was significantly more posterior than that in the natural head posture. The activity of the masseter and digastric muscles in the deliberate forward head posture was slightly increased. These results suggest that the condyle moves posteriorly in subjects with forward head posture.

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